Above the Influence Online Registration

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Student Name*

Grade*

Age*

Address*

Home Phone

Student Cell Phone

Parent Cell / Work Phone*

Parent Email*

How were you referred to this program?

Medical Information (Optional)

The staff of Above the Influence would like to make this program accessible and successful for each student involved. We request that you fill out this form, including any learning disabilities, medical conditions, or any medications being taken that you would like us to know about to make this program as beneficial and safe to your child as possible.

Please list any medical or psychological conditions:

Please list any current medications:

Please list any learning disabilities:

Please list any other information that you believe the staff should know, or that would help your child be successful in the program:

Parental Consent (Required)

I hereby consent to my child’s participation in this program. Further, I consent to the release of information related to my child’s attendance and participation in this program to the referring program (if applicable).